Legal/Corporate Name*

DBA*

Physical Address*

City*

State*

Zip Code*

Mailing Address (If different from physical address)

City

State

Zip Code

Telephone Number*

Date Business Started*

State of Incorporation*

Federal Tax ID*

Fax Number*

Hours of Operation*

Product/Service Sold*

Type of Entity
Sole ProprietorshipPartnershipCorporationLLCOther

Email Address*

Type of Business
RetailWholesaleBusiness ServicesConsumer ServicesRestaurant/BarOther

Website Address

Corporate Officer/Owner Name*

Title*

Length of Ownership*

Home Address*

City*

State*

Zip Code*

Ownership %*

Date of Birth*

Social Security Number*

Home Phone Number*

Cell Phone Number*

Corporate Officer/Owner Name*

Title*

Length of Ownership*

Home Address*

City*

State*

Zip Code*

Ownership %*

Date of Birth*

Social Security Number*

Home Phone Number*

Cell Phone Number*

Own/Lease*

Time at This Location*

Monthly Rent or Mortgage($)*

Date Lease Ends*

Business Landlord or Mortgage Bank*

Contact Name and/or Accout No.*

Office Mobile Number*

Business Name*

Contact or Account Number*

Phone Number*

Fax Number*

Business Name*

Contact or Account Number*

Phone Number*

Fax Number*

Current Processing Company*

No. of Terminals*

Avg. Monthly Credit Card Sales($)*

Avg. Monthly Total Sales($)*

Requested Advance Amount($)*

Terminal Type*

Prior/Current Cash Advance Company

Current Balance($)

Do you usually close business during part of the year?
YesNo

Any open State/Federal Tax Liens Against Business or Owner?
YesNo

Any Lawsuits or Judgmments Pending Against Business or Owner?
YesNo